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SEP-10-2004 11 : 15 AM MII)AS. AUTO. SERVICE 2093699430 P_ 04 <br /> • <br /> ■ ;. CA Uniform Waste and Used Tire Manifest �Illo Box 1 Integrated SaM mento, A OP32-12 <br /> � ����� �`�� PO Boz 1259 SsorameMo CA faypa2-t2 <br /> L'�L�L I°vtl P I L I I I Ll3 l �- _...___..__Manliest Number ,. .e. <br /> m w. ....� .,.. <br /> State of CA <br /> ;1WAre-ae7(03/03) INSTRUCTIONS ON BACK IAA - 16 51 2 81 j <br /> r,..` ALI.IMAGE TIRE&WHEEL ! <br /> 900 S.CHEROKEE LN.#1 <br /> LODL CA 95240 <br /> k <br /> Hauler's Business Phone - <br /> (include arca code) <br /> 1 I Hauler Exemption (if applicable) <br /> ❑Government ❑LEA Exempt <br /> Lead Oate(MNVOOtYY) Log Number <br /> l' t" '-r ; , _.__ ❑ Agriculture ❑Common Carrier' <br /> J Back Haul <br /> T: Indicate(if applicable)EJ In Transit <br /> License Plate Number Stitte Decal Number <br /> OCeMidentlaBiy Claim:The information provided in Part I and Part 11 of this form should be-considered confidential,proprietary,and/or trade secret.In <br /> accordance with Title 14•CCR,Section 17041 et.seq.should any member of the public request disclosure of this Information,I request that CIWMB contact <br /> me at the address and telephone number above. <br /> I certify that under penalty of perlttry ander the lay.-of the Stale or C.11ifomia that the intormation provided above i,true and correct, In Amltion,I am aware that tstslucatton of this <br /> lntotmatbn may mauh In aulprnalon,revaeatlon,or MIMI of mrtemil of ihr.Wn:In.Tire-,Hnnlnr Rr gmwntinn p,lmrntnt,ln Puhli-Rn!.rumea Coral?arollDn 42HR0 and may r@9UFI In cfvlf <br /> prnnniex up to Sm.non pmr dov.per viotation of admini%irntive pornaltie,uo to 55.000 oar violation per day 1•,dc:54ritx;d in Puhllr:Rr.,-.oun e.Cnor.-,orlinn 42%2. <br /> r <br /> Driver's Name rim Driverls% natut'e Date <br /> :,.i6N..'_-.o.+:,.:�<`...•.�.'M,.s-__y.�a....;—r..r4.:.:—.�sww:..'-' -r.T� <br /> Business <br /> �ar4+e Facility's Business Phone(include area code) <br /> Ir I <br /> Number III Street Address <br /> Addras3 Samc As Hauler <br /> r f <br /> mange Of Address <br /> city r _ <br /> State Z!'o Code _ <br /> Tire Types and Amounts - .._ . .. . . _......_..__.. Intended Use <br /> 1 ! ' '• C3 Passenger (]Oversize <br /> _. _ [IRetread/Fleuse <br /> Tire Program ID Site Suffix C <br /> Recycle <br /> Truck <br /> ___ ❑ <br /> 11 ---- - D Other <br /> Fuel 4 <br /> • i l Q <br /> Oispo al/La s ndlill <br /> '• <br /> Cornment Area <br /> oConfidentiallty Claim:The Information provided in Part I and Parr 11 of this form should be considered confidential,proprietary.and/or trade Secret. <br /> In accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information,I requeat that COMB <br /> contaet me M the address and telephone number above. <br /> I certify that under penalty of perjury under the laws of the Stale of Califoenifimat the information provirtM aftve is true and cerrrM..In aedlllon,I am aware mat talallicatlon of this <br /> informatlon may temill in civil penaltles up to$25.000 per day.per viWa•on or administggive paoaUi1;zL r In$5.000 per violation per day as described in Ntroltc R umes <br /> COP- <br /> awtIon A2962. <br /> r�. . . <br /> RepremilAtative Name(pAnt) 'Ae�iresentativtl tiignature Date Ase � <br /> Toll Free 1-866-896-0600 / www.ciwMb.ca.gov/Tires/ <br /> Wale:cIWM6 Copy Pink:Tire,Dealarl0ensrator7Grld-use Facility Copy Vnilow:Hauler Copy <br /> rnnM NQ na ra'74t1-ngvMR r;..:n.,n, a•. , <br /> ■ <br />